Mineralocorticoid Receptor Antagonist Use in Hypertension to Prevent Heart Failure

Mineralocorticoid receptor antagonists (MRAs) reduce cardiovascular mortality and heart failure (HF) hospitalizations across the spectrum of HF. Beyond their recognized benefits in patients with established HF, the value of MRA therapy may be undervalued for the prevention of HF in patients with hypertension. Emerging evidence indicates that a substantial proportion of patients considered to have "idiopathic" or "essential" hypertension have mineralocorticoid receptor overactivation by under-recognized mechanisms (such as, primary aldosteronism pathophysiology, cortisol dysregulation, and ligand-independent activation). The recognition that MRAs may address an operative mechanism of HF pathogenesis, and that implementation of therapy early in the course of hypertension may prevent the incidence of HF, suggests a new strategy to prevent HF that warrants further investigation. This review summarizes new evidence and theories which suggest that increased use of MRAs in hypertension may decrease incident HF by addressing common and under-recognized mechanisms of mineralocorticoid receptor overactivation.